Welcome to the May 2013 edition of i2P - Information to pharmacists.
Economic turbulence seems to now be arriving in Australia with forecasts of high inflation rates, which also means high interest rates following on.
This type of economic forecast also means that banks will be more fractious with their borrowers. They are already offside with pharmacy due to the high level of bankruptcies over the past two years.
There is a pent up demand for a general wage increase for pharmacists impacting at a point in this month where pharmacy gross profit generally, is in decline.
Volume 1 Number 1
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Volume 1 Number 3
Volume 1 Number 4
Volume 1 Number 5
Volume 1 Number 6
Volume 1 Number 7
Volume 2 Number 1
Volume 2 Number 2
Volume 2 Number 3
Volume 2 Number 4
Volume 2 Number 5
Volume 2 Number 6
Volume 2 Number 7
Volume 2 Number 8
Volume 2 Number 9
Volume 2 Number 10
Volume 2 Number 11
Volume 3 Number 1
Volume 3 Number 2
Volume 3 Number 3
Volume 3 Number 4
Volume 3 Number 5
Volume 3 Number 6
Volume 3 Number 7
Volume 3 Number 8
Volume 3 Number 9
Volume 3 Number 10
Volume 3 Number 11
Volume 4 Number 1
Volume 4 Number 2
Volume 4 Number 3
Volume 4 Number 4
Volume 4 Number 5
Volume 4 Number 6
Volume 4 Number 7
Volume 4 Number 8
Volume 4 Number 9
Volume 4 Number 10
Volume 4 Number 11
Volume 5 Number 1
Volume 5 Number 2
Volume 5 Number 3
Volume 5 Number 4
Neil Johnston is a pharmacist who trained as a management consultant. He was the first consultant to service the pharmacy profession and commenced practice as a full time consultant in 1972, specialising in community pharmacy management, pharmacy systems, preventive medicine and the marketing of professional services. He has owned, or part-owned a total of six pharmacies during his career, and for a decade spent time both as a clinical pharmacist and Chief Pharmacist in the public hospital system. He has been editor of i2P since 2000.
I recently received an email from Dr Ken Harvey the well-known academic from Latrobe University, who is trying to reform some aspects of the TGA, particularly in relation as to how drugs and complementary medicines are registered, and the quality of evidence used to support claims of efficacy.
It’s a subject that has gained traction since the beginning of the year, and there are a range of viewpoints that need to be sorted out so that coherent policies can be formulated that would be broadly supported by all health professionals (not just mainstream health professionals).
About the same time I received a communication from Gerald Quigley talking about the clinical and educational resources that exist within the Society of Hospital Pharmacists of Australia.
I reflected on both these communications and decided to publish them in a positive fashion, hopefully to create an ethical and clinical direction for community pharmacy.
Ken Harvey is highlighting the problem that the Pharmacy Guild of Australia ignited by not thinking through a proposal for a clinical promotion in conjunction with Blackmore’s Laboratories that involved the blanket recommendation of certain nutritional supplements with particular drugs prescribed for patients.
The PGA was heading in a suitable direction, but the method could not be considered ethical.
i2P offered comment at that time (even sympathy for the PGA which was unusual for us!).
Ken has unearthed a community pharmacy that seems to be following the original PGA promotional method, a method that has been universally condemned.
What was needed (and still is) was a pharmacist qualified in clinical nutrition responding to a patient request and taking a full history of all circumstances. Preferably, this pharmacist should have a degree of “arms-length” from the pharmacy owner, but that is not an absolute necessity.
After a full investigation of the patient’s circumstances and a need is found for nutritional supplements, then a recommendation can be ethically made.
In Ken’s actual experience, this service was being provided by an unqualified sales person in the manner of “would you like coke and fries with that?”
It has often been suggested by i2P that a range of pharmacist health practitioners specialising in lifestyle disorders should be available as a standard primary care service in a clinical setting. Some pharmacies have experimented with nurses in a pharmacy clinical setting, but as yet have not supported qualified pharmacists in this role.
It’s a long overdue development. Otherwise we are likely to see more unsuitable equivalents being provided, similar to that uncovered by Ken Harvey.
What follows is Ken’s letter to i2P and following on from that are comments by Gerald Quigley for professional service pharmacists to take on board.
Yesterday (May 1, 2012) I went to the Hawthorn Pharmore Pharmacy to get a repeat prescription of my wife’s simvastatin ‘script dispensed.
I was intrigued when a young female sales assistant recommended that BioCeuticals coenzyme Q10 should be purchased with the ‘script and provided a handout (as illustrated).
She had a very convincing and clearly well-scripted sales talk; does your wife lack energy or have sore muscles? Did you know that "statins" decrease Co Q10 levels? Did you know that your heart needs this important supplement if you are taking "statins"?
I was unkind enough to point out that this issue of “companion sales” had produced a lot of adverse publicity for pharmacy,
So I returned with the NPS and additional literature and asked for the pharmacist-in-charge to make contact. Regrettably, this has yet to happen.
I remain most disappointed by this pharmacy-consumer interaction.
Dr Ken Harvey, Adjunct Associate Professor, School of Public Health, LaTrobe University http://medreach.com.au VOIP (03) 90293697 | Mobile +614 1918 1910 | Fax: +613 9818 1875
Postscript: Subsequently a pharmacist from Pharmore Pharmacies did respond to my concerns and I took up her offer to make contact by telephone. She mentioned that Pharmore sales assistants had been trained by BioCeuticals which Pharmore believed was a reputable company and she felt the NPS advice was merely one opinion amongst others that she referenced.
Gerald Quigley’s comments follow and we would welcome reader comments as to how we might aggregate all input into a useful format to encourage community pharmacists to deliver optimum professional services.
For your consideration please:I have discovered a superb new educational resource!It’s called “Pharmacy Practice and Research” or “The Official Journal of the Society of Hospital Pharmacists of Australia”
And what a monthly read it is!!
I’ve never actually worked in a hospital pharmacy, and my exposure to that area of practice has been limited to ensuring that patients of mine could safely make the transition from the ward to their own home. This common issue is sometimes very challenging for a variety of reasons.On joining SHPA, I was seeking re-stimulation of my “illness” education, because my focus is on “wellness” education.
And I haven’t been disappointed at all.
I was supplied with four back issues of this Journal, and I’m astounded at the relevance of many of the articles to our roles in community Pharmacy.
If you want value for your educational and information dollar, I can’t recommend these journals more highly.
I’ve discovered things that other organizations don’t tell me.
I’ve learned about the issues of being admitted to hospital on a weekend.
I’ve discovered what a “Lipid Pharmacist” is, and their role in running a lipid clinic. What possibilities does that open up in service based pharmacies?
Perhaps new opportunities and new clinical practice.
And why not include a “nutrition” pharmacist, reviewing medicines and nutrient depletions?
In a rather frightening article, I read about unanswered health-related questions in community Pharmacy. Scary stuff, when you consider that we feel that we are doing the best by our patients. This is evidence based material clearly showing that we aren’t!
Or the impact on direct-to-consumer advertising of prescription medicines on the internet?
What ramifications might that have?
Is SHPA a hidden gem? Might be and worth considering for any professional pharmacy practitioner.
I have some comments on Ken Harvey’s exchange at the Pharmore Pharmacy. The Pharmore group I might add take their professional role very, very seriously, and in many instances are well in front of others in patient care.
At The International Science of Nutrition in Medicine and Healthcare Conference in Melbourne (where I chatted to Ken, and was attended by my count, THREE pharmacists), key research was given that “statins” deplete CoQ10, thereby affecting cognition.
GP questioning after that session showed naivety, but a real willingness to understand and advise. In other words, “to take responsibility”.
So do we pharmacists take responsibility or not? Do we have the balls? Or do we just hide behind “the evidence”. Well here’s evidence! But do we need a bit, some, lots or from what source before we accept and apply the results??
Or is it evidence that has to pass some other authority for a tick of approval before we act?
Are we very, very selective in what evidence we are happy with?
The process at the pharmacy in question was great, but far too aligned to “coke and fries”. The product concerned was BioCeuticals brand of CoQ10, “a practitioner only” product!
So where was the pharmacist who simply doesn’t understand what a ‘practitioner only’ product actually entails?? No doubt doing his low-margin, rapid turnaround dispensing with the resultant minimal “supply” fee!
It’s like my “bacon and egg comparison”. We can be involved or committed. In bacon and eggs, the chook is involved, but the pig is committed!
If I was started on a statin, and I was over 50, and I wasn’t given information from the pharmacist as to the potential effects of a statin on cognition, I’d be really annoyed. In fact, if my cognitive abilities decreased, and I wasn’t advised, and the pharmacist might reasonably be expected to know, might that be a reason to seek to speak to a legal advisor?
1. All parties to this conversation appear to be in agreement that the process at the Pharmore Pharmacy was not appropriate.
2. Excluding Ken Harvey, we also agree that the Pharmore group is a highly professional operation that appears to have slipped up on this occasion. Hopefully it is only a “one-off” incident.
3. Everybody has a notion of what constitutes “evidence”. In the case of official Pharmacy, nobody seems to argue a case for the evidence they are prepared to take responsibility for.
It certainly was confused in respect of the PGA/Blackmore’s issue.
It is a base that is definitely wider than promoted mainstream medical evidence – and even that differs according to which branch of medicine is involved.
4. i2P would even go one step further and claim that even when legitimate evidence is available to support the claims for coenzyme Q10, mainstream medicine practitioners simply ignore it, because they lack the experience to make a judgement for this type of treatment or are irrationally and strongly biased against any form of complementary medicine.
Further, i2P have uncovered reported incidence of fraudulent mainstream evidence that has caused us to rely more on our own clinical experience, rather than “toe” a mainstream medical party-line.
5. Pending clarification of legal issues, at least two of us agree that a patient may have an action against a pharmacist, if cognitive difficulties resulted from taking a prescribed “statin” without accompanying information and advice from that pharmacist regarding the use of coenzyme Q10.
Obviously, the evidence debate still has a long way to go before satisfaction sets in.
In conclusion, Gerald Quigley forwarded a comment that recently appeared in the March 2012 edition of the ACNEM Journal a GP reports:
“Throughout medical school, I was a big fan of evidence-based medicine, and I thought it was so convenient that almost everything a doctor needs to know is neatly summarized in the Australian Medicines Handbook and Therapeutic Guidelines.
Setting out to train in General Practice as I was I thought “what could possibly go wrong? The best available evidence is right there at my fingertips”.
How naïve was I? I soon discovered that clinical practice was more of an art than a science, and that evidence was much more than gaining confidence in one’s own clinical experience. Lowe and Brewster (2003. Evidence-based medicine and clinical practice. Journal of Paediatrics and Child Health. Vol 39, Issue 2 pp 145-146) point out that evidence is a synthesis of others’ experience with one’s own ie that the RCTs say in relation to one’s own clinical experience.
More often than not it is the combination of nutrients/anti-oxidants/doctor-patient interactions etc which make a treatment work, and this seldom equates to a double-blind RCT proving the effectiveness of single isolated factors."
That statement reflects the editor's personal belief, and I hope other pharmacists can rally behind that message and include it as part of their own perspective.